Provider Demographics
NPI:1760560312
Name:TABAK, CAROL A (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:TABAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1769 ESCALANTE WAY
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-5807
Mailing Address - Country:US
Mailing Address - Phone:650-697-8996
Mailing Address - Fax:
Practice Address - Street 1:1769 ESCALANTE WAY
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-5807
Practice Address - Country:US
Practice Address - Phone:650-697-8996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35466208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G354660Medicaid
CA00G354660Medicaid
00G354660Medicare ID - Type Unspecified